Download Psychological and behavioural considerations in young adult

Psychological and behavioural considerations in young adult
suffering from malignancy
Dr. BIKRAMJIT CHAKRABARTI, MD, DNB
Late in the winter of my seventeenth year, my mother decided I was
depressed, presumably because I rarely left the house, spent quite a lot
time in bed, read the same book over and over, ate infrequently, and
devoted quite a bit of my abundant free time to thinking about death.
This was the beginning of the book ‘The fault in our stars’, by John Green,
which was made a successful movie. Indeed this sentence depicts the
behavioural response after diagnosis of cancer in most individuals.
Psychological aspects of young adults and their responses to imminent doom are often left
uncared by the attending oncologists.
Problems: The impact of diagnosis and treatment of cancer on their physical appearance,
sexual development, and can lead to shame, social isolation, and regressive behaviour if not
addressed promptly. Interruptions of school or work due to treatment will have negative
consequences for their long-term career opportunities, financial status, and lifetime
earnings.
Young patients with cancer may also engage in risky behaviours (tobacco, alcohol, or
substance abuse) that may impair their health. Older age at cancer diagnosis, lower
household income, less education, no pulmonary-related cancer treatment, and no brain RT
were independently associated with a statistically significant relative risk of smoking
initiation. The risk factors associated with heavy drinking included fair or poor selfassessed health, depression, anxiety, somatization, activity limitations, and cancer-related
fears and uncertainty.
Younger patients (less than 50 years of age) may be more susceptible to anticipatory
nausea and vomiting, because they generally receive more aggressive chemotherapy and
have poorer emesis control than older patients. Young cancer patients 20 to 29 years of age
are significantly less likely to use professional mental health services than teens and older
patients 30 to 39 years of age.
Assessment: Young men and women go through developmental stages marked by rapid
changes in cognitive and emotional growth, and these issues need to be considered while
delivering developmentally appropriate psychosocial and supportive care to young
patients with cancer. Palmer et al have recently developed a Young Adult Oncology
Psychosocial Screening Tool to assist clinicians to support psychosocial coping during
active treatment and promote healthy post-treatment survivorship in young patients with
cancer. This screening tool has four main areas: the distress thermometer, the check list of
“areas of concern,” the tick box for information provision, and the signatures. Further
validation of this tool and its use will help clinicians to improve psychosocial care for AYA
patients with cancer, regardless of treatment location.
What should be done: During the treatment period, these patients should have the
opportunity to live as normal a life as possible, continue their education and/or careers, and
participate in the many milestones of their lives. Young adult patients diagnosed with cancer
should be recognized as a distinct age group that has unique medical and psychosocial
needs.
Peer support programs assist these patients and survivors in establishing and
maintaining relationships with their normal peers as well as with other young adult
patients with cancer, offer opportunities to achieve age-related developmental tasks
(building interpersonal and problem-solving skills), and promote positive psychosocial
growth.
Communicating information to patients can be challenging, especially since there are
several subgroups within the population with different levels of cognitive and emotional
development. It is very important to establish direct communication with the patients on
an individual basis, with sufficient sensitivity to each patient’s needs and preferences.
While some patients prefer not to receive direct communication about their cancer, others
may desire to take a more prominent role in the management of their care. For the latter
group, information should be provided directly to patients in an age-appropriate manner,
allowing time to process the information and deliver information in a caring manner.
Young adult patients prefer that information about their cancer and cancer-related risks be
communicated to them in a manner that is positive, respectful, and non-judgmental.
The physician should promote communication between patients and family members
(parents, spouse/partners, and siblings), provide information to family members and
partners about psychosocial support and behavioural services to increase awareness of the
possible psychosocial issues associated with diagnosis of cancer, consider family-based
intervention models from paediatrics (eg, parent support groups, Impact of Traumatic
Stressors Interview Schedule), establish direct communication with the individual patients,
providing age-appropriate information about their cancer, treatment options, and potential
side effects, thus reinforcing the importance of patient involvement in decision-making.
Face-to-face meetings, camp and retreat programs, online support groups may be helpful.
Some patients prefer not to share information about their cancer with their family in an
effort to shield their family members from some of the things they themselves worry about.
Therefore, obtain their permission to share information with other family members.
Behavioural therapy has been used in patients with anticipatory nausea and vomiting.
End of life care: In one retrospective review, a significant number of adolescents dying of
cancer felt that discussions about end-of-life occurred very close to death, thus allowing
very little time to psychologically prepare for death. It is imperative for healthcare
professionals not to assume that young cancer patients may be less inclined to discuss
death and other end-of-life issues. Discussion about end-of-life preferences should begin
early in treatment, but details should be individualized according to the preferences of the
patient and family. Many adolescents indicate a preference for dying at home, yet 80% die
in hospitals. Physicians with experience in palliative care should facilitate discussion about
end-of-life care issues such as nutrition/hydration, sedation treatment cessation, and place
of death. An advance care planning document is necessary for terminally ill patients with
metastatic cancer. Ongoing psychosocial support is extremely important during the
transition to end-of-life care. For family and friends, grief from loss may begin before death.
At the end of the novel I began my discussion with, Hazel Grace, the central character
suffering from recurrence of malignancy lives. She receives an e-mail from her boyfriend
Augustus who was her chief motivator in the peer group, but himself dies from cancer. The
mail included inspirational quotable: ‘The real heroes are not the people doing things, the
real heroes are people noticing things, paying attention. Almost everyone is obsessed with
leaving a mark upon the world. Bequeathing a legacy. Outlasting to be remembered. I do,
too. That’s what bothers me most, is being another unremembered casualty in the ancient
and inglorious war against disease’. That’s the end.